MEDICARE: ILEANA S. FASICK FUMERO MSCP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC1900X	Counseling Psychologist	7693	PR

General Provider Information

NPI Number	:	1194408179
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ILEANA S. FASICK FUMERO MSCP

Provider Business Mailing Address
First Line	:	100 CALLE PRINCIPE GUILLERMO
Second Line	:
City	:	GUAYNABO
State	:	PR
Zip	:	00969-5332
Country	:	US
Telephone Number	:	787-300-1015
Fax Number	:

Provider Business Practice Location Address
First Line	:	1704 CALLE PARANA
Second Line	:
City	:	SAN JUAN
State	:	PR
Zip	:	00926-3160
Country	:	US
Telephone Number	:	787-300-1015
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2023
Last Update Date	:	08/08/2023

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